Journal of Otolaryngology Head & Neck Surgery Category: Clinical Type: Research Article
Importance of Turbinectomy in Modern Clinical Practice
- Kara Babo1, Jennifer Fuller2, Natalie Niedzwiedz3, Rex Moulton-Barrett4*, Jory Statner5
- 1 Saint Louis University School Of Medicine, Missouri, United States
- 2 Department Of Otolaryngology Head And Neck Surgery, Harvard University, Massachusetts, United States
- 3 Department Of Otolaryngology Head And Neck Surgery, University Of California, Los Angeles, California, United States
- 4 Alameda Hospital, California, United States
- 5 Department Of Otolaryngology Head And Neck Surgery, McGill University, Montreal, Canada
*Corresponding Author:Rex Moulton-Barrett
Alameda Hospital, California, United States
Received Date: Apr 20, 2018 Accepted Date: Jul 23, 2018 Published Date: Aug 06, 2018
A retrospective clinical case series was performed to determine the benefits versus complications of turbinectomy. Over a six-year period, 86 patients, who were unresponsive to medical therapy, underwent either inferior turbinectomy for persistent nasal obstruction and/or middle turbinectomy for persistent migranous symptoms. Ninety percent of patients who underwent bilateral inferior turbinectomy, 100% undergoing unilateral inferior turbinectomy, 75% of patients undergoing bilateral middle turbinectomy, 95% undergoing combined middle and inferior turbinectomy, showed marked improvement or resolution of symptoms. Six percent of patients, specifically in the group who underwent inferior turbinectomy, developed a major complication of bleeding, requiring repacking of the nose. Eight percent of patients following inferior turbinectomy experienced persistent nasal obstruction which was secondary to nasal valvular collapse and not Empty Nose Syndrome (ENS). We believe that turbinectomy is a safe procedure in patients with turbinate hypertrophy with nasal obstruction and/or sinus headaches, who have failed maximal medical therapy, and in this population turbinectomy was not found to be a cause of ENS.
However, removing turbinate tissue (usually in excess) can have an undesirable, negative effects [2,5,6]. One such undesirable complication has been Empty Nose Syndrome (ENS). The term ENS was first introduced by Dr. Eugene Kern in 1994, after overhearing a Swedish colleague (Dr. Stenqvist) remarking on the “empty” appearance of the nasal CT scans of postoperative patients with a set of specific complaints . This set of complaints, or syndrome, is characterized by the sensation of the inability to breathe through the nose, coupled with the sensation of nasal dryness and may be associated with internal crusting, bleeding and local pain . The paradoxical sensation of the inability to breathe through the nose is thought to be due to the inability to sense airflow through the nasal passage . This is possibly due to the abnormal airflow pattern created (eddies rather than a laminar flow pattern), a partial or complete loss of the sense of smell may be a contributing factor [5-7,9]. These symptoms often become chronic and may cause clinical depression [6,7].
Chronic nasal obstruction which is secondary to inferior turbinate hypertrophy typically responds well to various forms of turbinectomy. Middle turbinate impaction on the nasal septum is an important cause of migraine sinus-type headaches. Middle turbinectomy for medically refractory migraine is an effective treatment for this problem . Sinus related headaches, are commonly treated in error with classical migraine medications. Chronically swollen or hypertrophied turbinates may occur with allergy and may be associated with sinusitis , which may be acute, recurrent or chronic and may cause sinus headaches  in the frontal, retro-bulbar, malar and maxillary areas . Acknowledging the above, the current paper is intended to re-evaluate the efficacy of turbinectomy in modern clinical practice and evaluate whether or not turbinectomy is a cause of empty nose syndrome in the above group of patients [3,4].
The concept that removal of turbinate tissue always leads to a permanent effect on mucociliary clearance which then results in nasal damage is based on older literature which was written at a time when hypertensive patients often received alpha blockers, the latter are a well accepted cause for dry nose secondary to reduced mucus secretory output . The current study provides an evaluation of the utility of bilateral inferior and middle turbinectomy for the treatment of chronic nasal obstruction and sinus headache, respectively, specifically in patients with a ‘crowded nasal airway’.
PATIENTS AND METHODS
|Specific Procedure||N of Specific Procedures||N Undergoing Septoplasty at Time of Turbinectomy||Mild to No Improvement (SUIS 0-29)||% of Patients with Mild to No Improvement (<30%)||Moderate Improvement (SUIS 30-69)||Significant Improvement (SUIS 70-99)||Complete Resolution (SUIS 100)||% of Patients with Moderate to Complete Resolution (≥30%)|
|Combined, bilateral middle and inferior||21||15||1||4.8%||4||12||4||95.2%|
Sixty of the 86 patients also underwent a partial submucous resection of the septum when septal deviation was deemed to contribute towards nasal obstruction in the presence of turbinate impaction onto the septum, specifically these patients were divided into sub-groups: Inferior versus middle or combined and unilateral versus bilateral turbinectomy (Table 2). The average SUIS for patients following septoplasty at the time of turbinectomy is shown in table 2.
|Specific Procedure with Septoplasty||N Undergoing Septoplasty||Average SUIS|
|Combined, bilateral middle and inferior||15||77.9|
Forty-two percent of patients who underwent inferior turbinectomy also had headaches which were not related to the middle turbinate but rather were non-allergic migrainous or simple tension type in nature.
In the combined inferior and middle turbinectomy group, inferior turbinectomy was performed for nasal obstruction in all patients and headache was the indication for middle turbinectomy in 75% of patients. 25% of patients underwent middle turbinectomy when polypoid changes to the middle turbinate were associated with nasal obstruction and not because of headache. Within the group who underwent bilateral inferior turbinectomy, 22 patients (37.3%) had total resection, 4 (6.8%) had subtotal resection and 33 patients (55.9%) underwent partial resection. Within the group who underwent bilateral inferior turbinectomy, 22 patients (37.3%) had partial resections. Two patients underwent isolated unilateral inferior turbinectomy by partial resection only.
Patients undergoing bilateral middle turbinectomy included 3 patients (75%) partial resection and 1 (25%) with total resection. Within the combined group 7 (33%) underwent inferior and 10 (47.6%) middle turbinate total resections, 1 (4.8%) underwent subtotal middle turbinectomy. There were 8 inferior and 10 middle turbinectomy (non-combined surgery) patients who underwent partial resection. The average SUIS for patients undergoing varying surgical procedures for each group is outlined in table 3. Seventy-nine patients (89.9%) reported moderate to complete resolution of symptoms following inferior turbinectomy (Table 1). All patients who underwent bilateral middle turbinectomy and/or unilateral inferior turbinectomy reported moderate to complete resolution of symptoms. Twenty patients (95.2%) who underwent combined bilateral middle and inferior turbinectomy reported moderate to complete resolution. Six patients (10.2%) following bilateral inferior turbinectomy and 1 patient (4.85) following combined middle and inferior turbinectomy reported mild to no improvement (SUIS<30) of symptoms (Table 1).
|Resection Classification||Bilateral Inferior (n)||Unilateral Inferior (n)||Bilateral Middle||Combined (n)|
|Total||85.5 (22)||N/A||80 (3)||67.3 (17)|
|Subtotal||93.7 (4)||N/A||N/A||92 (7)|
|Partial||74.1 (33)||92.5 (2)||100 (1)||84.3 (18)|
In 15 patients (19.89.8%) with less than moderate improvement or less (SUIS< 69) of nasal obstruction, internal or external nasal valvular collapse was found as a cause in all but one patient (93%). Complications, such as bleeding requiring repacking, occurred in 5 (6%) of the 86 patients and in all 5 patients bleeding was due to inferior turbinectomy. One patient reported persistent nasal obstruction without valvular collapse and was found to breath nasally during multiple office examinations and by family members at home, yet the patient described the sensation of loss of the sense of airflow. There were no intranasal findings to suggest crusting, dryness or an excessive size of the intranasal cavity.
Patient follow-up ranged from 12 months (1 year) to 78 months (6.5 years), with a mean of 42 months (3.5 years). Patient age ranged from 17 to 95 years of age, with a mean of age of 56 of which there were 47 males and 39 females.
In the current case series, postoperative ENS did not occur despite a reported frequency of between 9 and 15 percent in the literature . Patients who underwent bilateral inferior turbinectomy were at higher risk of ENS and were followed for up to 78 months (5.9 years, with an average of 42 weeks or 3.5 years) without evidence for evolving atrophic rhinitis or other symptoms of ENS. One large study reported a 7.1 year interval for symptoms of atrophic rhinitis to appear after turbinectomy underscoring the need for long term follow-up of these patients .
There was a consistent finding of nasal valvular collapse in patients who failed to respond to inferior turbinectomy in our series. Most often, the latter group of patients then underwent nasal valvular surgery using spreader grafts with correction of the persistent nasal obstruction.
Fear of developing post-operative ENS may lead clinicians to an under-utilization of turbinectomy in patients with ‘crowded nasal airways’ associated with nasal septal impaction of the inferior and or middle turbinate and nasal obstruction and/or sinus type headache, respectively.
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Citation:Babo K, Fuller J, Niedzwiedz N, Moulton-Barrett R, Statner J (2018) Importance of Turbinectomy in Modern Clinical Practice. J Otolaryng Head Neck Surg 4: 021.
Copyright: © 2018 Kara Babo, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.